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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601542
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:21:05 PM

Document Has Been Signed on 12/05/2022 04:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WILKIE HOMEFACILITY NUMBER:
198601542
ADMINISTRATOR:MARGARITA NUNEZ RENTERIAFACILITY TYPE:
735
ADDRESS:17234 WILKIE AVETELEPHONE:
(310) 538-8599
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 3CENSUS: 3DATE:
12/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Ronald Bautista AdministratorTIME COMPLETED:
04:35 PM
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LPA conducted an announced visit to facility. LPA Interviewed Administrator regarding the SIR in process of being reported to Regional Center and APS over the phone, while LPA was at the facility on other business. LPA received the following information: Staff noticed bruising of unknown origin on Client C1. During a behavior C1 is known to hit self and others. At this point it was not known what incident might have caused the bruising found while C1 was performing ADL's with staff assistance. Administrator informed LPA that he was in the midst of investigating the bruising, LPA observed registered nurse perform physical assessment of client bruising. Staff attempted to have C1 state how he obtained the bruising, C1 would not respond how he obtained the bruising. While LPA was conducting interviews with administrator staff assisted C1 with attending his day program, while staff was escorting C1 to transportation C1 entered facility van and begin to strike himself in the face blooding up his nose and facial area. C1 was visibly agitated and inflicted self-injurious bleeding to areas in his face. LPA observe staff attempt to calm, resident however C1 became more agitated and it took several minutes to calm C1 , LPA did observe C1 strike staff. Administrator was able to assist staff in gaining control of the client LPA did not observe any physical restraints on client staff was able to verbally assist C1 in de-escalating agitation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Ronald Bautista Administrator and copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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